Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: a pooled analysis of ten prospective studies

The cost of inaction: a global tool to inform nutrition policy and investment decisions on global nutrition targets

At present, the world is off-track to meet the World Health Assembly global nutrition targets for 2025. Reducing the prevalence of stunting in children, low birthweight, and anaemia in women and increasing breastfeeding are among the prioritized global nutrition targets for all countries. Governments and development partners need evidence-based data to understand the true costs and consequences of policy decisions and investments. Yet there is an evidence gap on the health, human capital, and economic costs of inaction on preventing undernutrition for most countries. The Cost of Inaction tool, and expanded Cost of Not Breastfeeding tool, provide country-specific data to help to address the gaps. Every year undernutrition leads to 1.3 million cases of preventable child and maternal deaths. In children, stunting results in the largest economic burden yearly at US$548 billion (0.7% of GNI), followed by US$507 billion for sub-optimal breastfeeding (0.6% global GNI), US$344 billion (0.3% of GNI) for low birthweight and US$161 billion (0.2% of GNI) for anaemia in children. Anaemia in WRA costs US$113 billion (0.1% of GNI) globally in current income losses. Accounting for overlap in stunting, suboptimal breastfeeding, and low birthweight, the analysis estimates that preventable undernutrition cumulatively costs the world at least US$761 billion per year, or $2.1B per day. The variation in the regional and country-level estimates reflect the contextual drivers of undernutrition. In the lead up to the renewed WHA targets and Sustainable Development Goals to 2030, the data generated from these tools are powerful information for advocates, governments, and development partners to inform policy decisions and investments into high-impact low-cost nutrition interventions. The costs of inaction on undernutrition continue to be substantial, and serious coordinated action on the global nutrition targets is needed to yield the significant positive human capital and economic benefits from investing in nutrition.

Specialized nutritious foods and behavior change communication interventions during the first 1000 d of life to prevent stunting: a quasi-experimental study in Afghanistan

BACKGROUND

Considerable evidence supports the effectiveness of nutritional supplementation with or without nutrition education in preventing stunting in developing countries, but evidence from Afghanistan is scarce.

OBJECTIVES

This project aimed to assess the effectiveness of specialized nutritious food (SNF), social and behavior change communication (SBCC) intervention to prevent stunting among children under 2 y during the first 1000 d of life in Badakhshan, Afghanistan.

METHODS

We used a community-based quasi-experimental pre-post study design with a control group. Pregnant and lactating women received a monthly ration of 7.5 kg of super cereal (250 g/d) during pregnancy and the first 6 mo of breastfeeding. Children aged 6-23 mo received 30 sachets of medium-quantity lipid-based nutrient supplement (50 g/sachet/d) monthly. We compared pre- and postintervention assessments of the intervention and control groups to isolate the effect of the intervention on key study outcomes at the endline by difference-in-differences (DID) estimates.

RESULTS

A total of 2928 and 3205 households were surveyed at baseline and endline. DID estimates adjusted for child, maternal, and household characteristics indicated a significant reduction in stunting (DID: -5% (95% confidence interval [CI]: -9.9, -0.2) and underweight (DID: -4.6% (95% CI: -8.6, -0.5) among children <2 y of age. However, DID estimates for wasting among children in the intervention and control groups were not significantly different (DID: -1.7 (95% CI: -5.1, 1.6). Furthermore, exposure to the SBCC messages was associated with improvements in the early initiation of breastfeeding (DID: 19.6% (95% CI: 15.6, 23.6), exclusive breastfeeding under 6 mo (DID: 11.0% (95% CI: 2.3, 19.7), minimum meal frequency (DID: 23% (95% CI: 17.7, 28.2), and minimum acceptable diet (DID: 13% (95% CI: 9.8, 16.3).

CONCLUSIONS

The provision of SNF in combination with SBCC during the first 1000 d of life was associated with reduction in stunting and underweight and improvements in infant and young child feeding practices among children under 2 y of age. This trial was registered at clinicaltrials.gov as NCT04581993.

Effectiveness of acute malnutrition treatment with a simplified, combined protocol in Central African Republic: An observational cohort study

A simplified, combined protocol admitting children with a mid-upper-arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready-to-use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115-<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango-Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context.

Preoperative Malnutrition Increases Risk of In-Hospital Mortality, Major Infection, and Longer Intensive Care Unit Stay After Ventricular Septal Defect Closure

BACKGROUND

High energy requirements and poor feeding can lead to growth failure in patients with ventricular septal defect (VSD), but effects of preoperative malnutrition on surgical outcomes are poorly understood, especially in low-resource settings.

METHODS AND RESULTS

We analyzed a cohort of children <5 years of age undergoing VSD closure at 60 global centers participating in the International Quality Improvement Collaborative for Congenital Heart Disease, 2015 to 2020. We calculated adjusted odds ratios (ORs) for in-hospital death and major infection and adjusted coefficients for duration of intensive care unit stay for 4 measures of malnutrition: severe wasting (weight-for-height Z score, <-3), moderate wasting (-3

CONCLUSIONS

Malnutrition was associated with mortality, infection, and longer intensive care unit stay in a global cohort of children undergoing VSD closure.

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Key Words

• congenital heart disease
• global health
• malnutrition
• mortality
• ventricular septal defect

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MESH Headings

• Humans
• Heart Septal Defects, Ventricular/surgery
• Heart Septal Defects, Ventricular/mortality
• Heart Septal Defects, Ventricular/complications
• Male
• Female
• Infant
• Hospital Mortality
• Child, Preschool
• Length of Stay/statistics & numerical data
• Malnutrition/mortality
• Malnutrition/epidemiology
• Malnutrition/diagnosis
• Risk Factors
• Cardiac Surgical Procedures/adverse effects
• Intensive Care Units/statistics & numerical data
• Nutritional Status
• Postoperative Complications/epidemiology
• Postoperative Complications/mortality
• Retrospective Studies
• Risk Assessment
• Time Factors

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Grants

• P30 DK040561 NIDDK NIH HHS
• National Institutes of Health

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Affiliation(s)

Rachel E. Wittenberg Harvard Medical SchoolBostonMAUSA
Kimberlee Gauvreau Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Christopher P. Duggan Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Xinwei Du Shanghai Children’s Medical CenterShanghaiChina
Do Giang Nhi Dong 1Ho Chi Minh CityVietnam
Kishore Jayanthi Star HospitalHyderabadIndia
Nestor Sandoval Fundación Cardioinfantil y LaCardioBogotáColombia
Sivakumar Sivalingam Institut Jantung NegaraKuala LumpurMalaysia
Xiaolei Zhao TEDA International Cardiovascular HospitalTianjinChina
Kathy J. Jenkins Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA

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How age and sex affect treatment outcomes for children with severe malnutrition: A multi-country secondary data analysis

Age and sex influence the risk of childhood wasting. We aimed to determine if wasting treatment outcomes differ by age and sex in children under 5 years, enroled in therapeutic and supplementary feeding programmes. Utilising data from stage 1 of the ComPAS trial, we used logistic regression to assess the association between age, sex and wasting treatment outcomes (recovery, death, default, non-response, and transfer), modelling the likelihood of recovery versus all other outcomes. We used linear regression to calculate differences in mean length of stay (LOS) and mean daily weight gain by age and sex. Data from 6929 children from Kenya, Chad, Yemen and South Sudan was analysed. Girls in therapeutic feeding programmes were less likely to recover than boys (pooled odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.72-0.97, p = 0.018). This association was statistically significant in Chad (OR: 0.61, 95% CI: 0.39-0.95, p = 0.030) and Yemen (OR: 0.47, 95% CI: 0.27-0.81, p = 0.006), but not in Kenya and South Sudan. Multinomial analysis, however, showed no difference in recovery between sexes. There was no difference between sexes for LOS, but older children (24-59 months) had a shorter mean LOS than younger children (6-23 months). Mean daily weight gain was consistently lower in boys compared with girls. We found few differences in wasting treatment outcomes by sex and age. The results do not indicate a need to change current programme inclusion requirements or treatment protocols on the basis of sex or age, but future research in other settings should continue to investigate the aetiology of differences in recovery and implications for treatment protocols.

Drivers of change in weight-for-height among children under 5 years of age in Ethiopia: Risk factors and data gaps to identify risk factors

The prevention of wasting should be a public health priority as the global burden of acute malnutrition is still high. Gaps still exist in our understanding of context-specific risk factors and interventions that can be implemented to prevent acute malnutrition. We used data from the four rounds of the Ethiopia Demographic and Health Survey (2000-2016) to identify risk factors that have contributed to the change in weight-for-height z-score (WHZ) among children under 5 years of age. We performed a pooled linear regression analysis followed by a decomposition analysis to identify relevant risk factors and their relative contribution to the change in WHZ. Modest improvements in WHZ were seen between 2000 and 2016. The sharpest decrease in mean WHZ occurred from birth to 6 months of age. Perceived low weight at birth and recent diarrhoea predicted a decline in WHZ among children aged 0-5, 6-23 and 23-59 months. Less than 50% of the change in WHZ was accounted for by the change in risk factors included in our regression decomposition analysis. This finding highlights data gaps to identify context-specific wasting risk factors. The decline in the prevalence of recent diarrhoea (15% of the improvement), decline in low birth size (7%-9%), and an increase in wealth (15%-30%) were the main risk factors that accounted for the explained change in WHZ. Our findings emphasize the importance of interventions to reduce low birthweight, diarrhoea and interventions that address income inequities to prevent acute malnutrition.

Mortality risk in infants receiving therapeutic care for malnutrition: A secondary analysis

Small and nutritionally at-risk infants aged under 6 months (<6 months) are at high risk of death, but important evidence gaps exist on how to best identify them. We aimed to determine associations between anthropometric deficits and mortality among infants <6 months admitted to inpatient therapeutic care. A secondary analysis of 2002-2008 data included 5034 infants aged <6 months from 12 countries. We estimated the prevalence, concurrence, and severity of wasted, stunted, and underweight, as stand-alone indicators, and using the Composite Index of Anthropometric Failure (CIAF), which combines these indicators into six subgroups of single and multiple anthropometric deficits and into one combined indicator called CIAF. We used logistic regression to examine the association of different anthropometric deficits with in-programme mortality. Among 3692 infants aged <6 months with complete data, 3539 (95.8%) were underweight, 3058 (82.8%) were wasted, 2875 (77.8%) were stunted and 3575 (96.8%) had CIAF. Infants with multiple anthropometric deficits were presented with significantly lower anthropometric indices, that is, they were more severely wasted, stunted and underweight. A total of 141 infants died during inpatient therapeutic care. Among these, severely wasted (116) and severely underweight (138) infants had higher odds of mortality than normal infants (odds ratio [OR] = 2.1, 95% confidence interval [CI]: 1.2-2.7, p = 0.009, and OR = 3.3, 95% CI: 0.8-13.6, p = 0.09, respectively). Boys had higher odds of inpatient mortality than girls (OR = 1.40, 95% CI: 1.02-1.92, p = 0.03). Mortality was only observed in infants <6 months presenting multiple anthropometric deficits, although their odds of mortality were not significant, for example, OR = 2.4, 95% CI: 0.5-10.0, p = 0.21 for stunted, wasted and underweight infants <6 months. In conclusion, multiple anthropometric deficits (CIAF) is common among infants <6 months and may be reported in nutrition care programmes and surveys. Both weight-for-length/height z-score and weight-for-age z-score were found to be useful indicators for programme admission and in-programme prognosis. Future work needs to explore which better accounts for admission bias. Boys appear to be most at-risk of dying while receiving malnutrition therapeutic care. Programmes should ensure that all infants receive timely, evidence-based, effective care.

Effectiveness of a nonweight-based daily dosage of ready-to-use therapeutic food in children suffering from uncomplicated severe acute malnutrition: A nonrandomized, noninferiority analysis of programme data in Afghanistan

Severe acute malnutrition (SAM) remains a major global public health problem. SAM cases are treated using ready-to-use therapeutic food (RUTF) at a dosage of ∼200 kcal/kg/day per the standard treatment protocol (STD). Emerging evidence on simplifications to the standard protocol, which among other adaptations, includes reducing the daily RUTF dosage, indicates that it is effective and safe for treating children with SAM. In response to a foreseen stock shortage of RUTF, the government of Afghanistan endorsed the temporary use of a modified treatment protocol in which the daily RUTF dosage was prescribed at 1000 kcal/day (irrespective of body weight) until the child achieved moderate acute malnutrition status (weight-for-height z-score ≥ -3 or mid-upper arm circumference [MUAC] ≥ 115 mm), at which point 500 kcal/day was prescribed until cured (modified treatment protocol [MTP]). In this paper, we report the results of this nonweight-based daily RUTF dosage experience. Data of 2042 children with SAM, treated using either the STD protocol (n = 269) or the MTP protocol (n = 1773) from August 2019 to March 2021 in five provinces, were analyzed. The per-protocol analyses confirmed noninferiority of MTP protocol when compared to STD protocol for recovery rate [93.3% vs. 90.2%; ∆ (95% confidence interval, CI) = 3.1 (-0.9; 7.2) %] and length-of-stay [82.6 vs. 75.6 days; ∆ (95% CI) = 6.9 (3.3; 10.5) days], considering the margin of noninferiority of -10% and +14 days, respectively. Weight gain velocity was smaller in the MTP protocol group than in the STD protocol group [3.7 (1.7) vs. 5.2 (2.9) g/kg/day; ∆ (95% CI) = -1.5 (-1.8, -1.2); p < 0.001]. The STD group had a significantly higher mean than the MTP group for absolute MUAC gain [∆ (95% CI) = 1.7 (1.0; 2.3) mm; p < 0.001] and the MUAC velocity [∆ (95% CI) = 0.29 (0.20; 0.37) mm/week; p < 0.001]. Our results confirm the noninferiority of a nonweight-based daily dosage and support the endorsement of this modification as an alternative to the standard protocol in resource-constrained contexts.

Integration of Acute Malnutrition Treatment Into Integrated Community Case Management in Three Districts in Southern Mali: An Economic Evaluation

BACKGROUND

Enabling community health workers (CHWs) to treat acute malnutrition improves treatment access and coverage. However, data on the cost and cost-effectiveness of this approach is limited. We aimed to cost the treatment at scale and determine the cost-effectiveness of different levels of supervision and technical support.

METHODS

This economic evaluation was part of a prospective nonrandomized community intervention study in 3 districts in Mali examining the impact of different levels of CHW and health center supervision and support on treatment outcomes for children with severe acute malnutrition. Treatment admission and outcome data were extracted from the records of 120 participating health centers and 169 CHW sites. Cost data were collected from accountancy records and through key informant interviews. Results were presented as cost per child treated and cured. Modeled scenario sensitivity analyses were conducted to determine how cost-efficiency and cost-effectiveness estimates change in an equal scale scenario and/or if the supervision had been done by government staff.

RESULTS

In the observed scenario, with an unequal number of children, the average cost per child treated was US$203.40 in Bafoulabé where a basic level of supervision and support was provided, US$279.90 in Kayes with a medium level of supervision, and US$253.9 in Kita with the highest level of supervision. Costs per child cured were US$303.90 in Bafoulabé, US$324.90 in Kayes, and US$311.80 in Kita, with overlapping uncertainty ranges.

CONCLUSION

Additional supervision has the potential to be a cost-effective strategy if supervision costs are reduced without compromising the quality of supervision. Further research should aim to better adapt the supervision model and associated tools to the context and investigate where efficiencies can be made in its delivery.

The Socio-Environmental Determinants of Childhood Malnutrition: A Spatial and Hierarchical Analysis

Despite a remarkable reduction in global poverty and famines, substantial childhood malnutrition continues to persist. In 2017, over 50 million and 150 million young children suffered from acute malnutrition (wasting) and chronic malnutrition (stunting), respectively. Yet, the measurable impact of determinants is obscure. We evaluate proposed socio-environmental related determinants of stunting and wasting across Kenya and Nigeria and quantify their effectiveness. We combine health and demographic data from Kenya and Nigeria Demographic Health Surveys (2003, 2008-2009, 2013, 2014) with spatially explicit precipitation, temperature, and vegetation data. Geospatial and disaggregated data help to understand better who is at risk and where to target mitigation efforts. We evaluate the responsiveness of malnutrition indicators using a four-level random intercept hierarchical generalized logit model. We find that spatial and hierarchical relationships explain 28% to 36% of malnutrition outcome variation. Temporal variation in precipitation, temperature, and vegetation corresponds with more than a 50% change in malnutrition rates. Wasting is most impacted by mother's education, family wealth, clinical delivery, and vaccinations. Stunting is most impacted by family wealth, mother's education, clinical delivery, vaccinations, and children asymptomatic of fever, cough, or diarrhea. Remotely monitored climatic variables are powerful determinants, however, their effects are inconsistent across different indicators and locations.

Prognostics of multiple malaria episodes and nutritional status in children aged 6 to 59 months from 2013 to 2017 in Dangassa, Koulikoro region, Mali

BACKGROUND

In Africa, the relationship between childhood nutritional status and malaria remains complex and difficult to interpret. Understanding it is important in the improvement of malaria control strategies. This study aimed to assess the influence of nutritional status on the occurrence of multiple malaria episodes in children aged 6 to 59 months between 2013 and 2017 living in the village of Dangassa, Mali.

METHODS

A community-based longitudinal study was conducted using cross-sectional surveys (CSSs) at the beginning (June) and end (November) of the malaria transmission season associated with passive case detection (PCD) at the Dangassa Community Health Centre. Children with asymptomatic malaria infection during cross-sectional surveys were selected and their malaria episodes followed by PCD. Malaria indicators in person-months were estimated using an ordinal-logistic model repeated on subjects during follow-up periods.

RESULTS

The incidence rate (IR) during the period of high transmission (June to October), for 1 episode and for 2 + episodes peaked in 2013 with 65 children (IR = 95.73 per 1000 person-months) and 24 cases (IR = 35.35 per 1000 person-months), respectively. As expected, the risk of multiple episodes occurring during the period of high transmission was 3.23 compared to the period of low transmission after adjusting for other model parameters (95% CI [2.45-4.26], p = 0.000). Children with anaemia were at high risk of having multiple episodes (OR = 1.6, 95% CI [1.12-2.30], p = 0.011). However, the risk of having 2 + episodes for anemic children was higher during the period of low transmission (RR = 1.67, 95% CI [1.15-2.42], p = 0.007) compared to the period of high transmission (RR = 1.58, 95% CI [1.09-2.29], p = 0.016). The trend indicated that anemic and underweight children were significantly associated with multiple malaria episodes during the period of low transmission (p < 0.001).

CONCLUSION

Results show that multiple episodes of malaria are significantly related to the nutritional status (anaemia and underweight) of the child during the two transmission seasons and more pronounced during the dry season (period of low transmission). Further research including other malnutrition parameters will be needed to confirm these findings.

Effect of a simplified approach on recovery of children 6-59 months with wasting in Ethiopia: A noninferiority, cluster randomized controlled trial

Worldwide, nearly 45 million children under the age of 5 years were affected by wasting in 2022. Ethiopia has been challenged by disasters increasing the caseload of children with wasting. This study aimed to determine the effect of a simplified approach on recovery of children with acute malnutrition as compared with the standard protocol. A cluster randomized, controlled, noninferiority trial was carried out in three regions of Ethiopia from December 4, 2021, to July 30, 2022. A total of 58 clusters (health posts) were randomized into intervention and control groups. Children with SAM in the intervention groups received two sachets of Ready-to-Use Therapeutic Food (RUTF), whereas children in the control groups received RUTF based on their body weight. Children with moderate acute malnutrition (MAM) received one sachet of RUTF and one sachet of Ready-to-Use Supplementary Food (RUSF) daily in the intervention and control groups, respectively. Per protocol (PP) and intention-to-treat analysis were used to compare recovery at a noninferiority margin of 15%. Data were collected from 55 health posts and 1032 children. In the PP analysis, the recovery rate of children with wasting among the simplified group (97.8%) was noninferior to the standard protocol group (97.7%), p = 0.399. The RUTF cost per treatment of child with SAM was 56.55 USD for the standard versus 42.78 USD for the simplified approach. The simplified approach is noninferior to the standard protocol in terms of recovery and has a lower cost of RUTF. Further study is recommended to assess the effectiveness of the simplified approach in emergency contexts.

Age- and height-dependent bias of underweight and overweight assessment standards for children and adolescents

Background

Precision in evaluating underweight and overweight status among children and adolescents is paramount for averting health and developmental issues. Existing standards for these assessments have faced scrutiny regarding their validity. This study investigates the age and height dependencies within the international standards set by the International Obesity Task Force (IOTF), relying on body mass index (BMI), and contrasts them with Japanese standards utilizing the percentage of overweight (POW).

Method

We scrutinized a comprehensive database comprising 7,863,520 children aged 5-17 years, sourced from the School Health Statistics Research initiative conducted by Japan's Ministry of Education, Culture, Sports, Science, and Technology. Employing the quantile regression method, we dissected the structure of weight-for-height distributions across different ages and sexes, quantifying the potentially biased assessments of underweight and overweight status by conventional criteria.

Results

Applying IOFT criteria for underweight assessment revealed pronounced height dependence in males aged 11-13 and females aged 10-11. Notably, a discernible bias emerged, wherein children in the lower 25th percentile were classified as underweight five times more frequently than those in the upper 25th percentile. Similarly, the overweight assessment displayed robust height dependence in males aged 8-11 and females aged 7-10, with children in the lower 25th percentile for height deemed obese four or five times more frequently than their counterparts in the upper 25th percentile. Furthermore, using the Japanese POW criteria for assessment revealed significant age dependence in addition to considerably underestimating the percentage of underweight and overweight cases under the age of seven. However, the height dependence for the POW criterion was smaller than the BMI criterion, and the difference between height classes was less than 3-fold.

Conclusion

Our findings underscore the intricacies of age-dependent changes in body composition during the growth process in children, emphasizing the absence of gold standards for assessing underweight and overweight. Careful judgment is crucial in cases of short or tall stature at the same age, surpassing sole reliance on conventional criteria results.

The Cost and Cost-Effectiveness of an Integrated Wasting Prevention and Screening Intervention Package in Burkina Faso and Mali

BACKGROUND

Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting.

OBJECTIVES

This study's objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC).

METHODS

Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child-contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage.

RESULTS

In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali.

CONCLUSIONS

Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Associations between Shared Sanitation, Stunting and Diarrhoea in Low-Income, High Density Urban Neighbourhoods of Maputo, Mozambique - a Cross-Sectional Study

INTRODUCTION

Shared sanitation facilities are used by over 500 million people around the world. Most research evidence indicates that shared sanitation conveys higher risk than household sanitation for many adverse health outcomes. However, studies often fail to account for variation between different types of shared facilities. As informal housing development outpaces sanitation infrastructure, it is imperative to understand which components of shared facilities may mitigate the health risks of shared sanitation use.

METHODS

This cross-sectional study determines whether sanitation improvement or compound hygiene were associated with stunting or diarrhoeal prevalence in children under five living in Maputo, Mozambique who rely on shared sanitation facilities. The study uses logistic and linear multivariable regression analysis to search for associations and control for potential confounding factors.

RESULTS

346 children (43.9%) in the study population were stunted. Each unit increase in sanitation score was associated with an approximate decrease of 22% in the odds of stunting (OR: 0.78, CI: 0.66, 0.92), and an increase in height of 0.23 height-for-age z-scores (CI: 0.10, 0.36). There was no evidence that the compound hygiene score was associated with height as measured by stunting (OR: 1.05, CI: 0.87, 1.26) or z-score (-0.06, CI: -0.21, 0.09). Neither sanitation nor compound hygiene score were associated with diarrhoea in the population.

CONCLUSIONS

Use of an improved shared latrine is associated with decreased odds of stunting. There is no evidence of an association between latrine improvement and diarrhoea. Further investigation is necessary to isolate attributes of shared sanitation facilities that may reduce health risks.

Risk factors for food contamination among children discharged from community management of acute malnutrition programmes in South Sudan: A cross-sectional study and hazard analysis critical control point approach

Children under-5 years of age are particularly vulnerable to severe acute malnutrition (SAM), and the risk factors associated with relapse to SAM are poorly understood. Possible causes are asymptomatic or symptomatic infection with enteric pathogens, with contaminated food as a critical transmission route. This cross-sectional study comprised a household survey with samples of child food (n = 382) and structured observations of food preparation (n = 197) among children aged 6-59 months that were discharged from treatment in community management of acute malnutrition (CMAM) programmes in South Sudan. We quantified Escherichia coli and total coliforms (TCs), measured in colony forming units per g of food (CFU/g), as indicators of microbial contamination of child food. A modified hazard analysis critical control point (HACCP) approach was utilised to determine critical control points (CCPs) followed by multivariate logistic regression analysis to understand the risk factors associated with contamination. Over 40% (n = 164) of samples were contaminated with E. coli (43% >0 E. coli CFU/g, 95% CI 38%-48%), and 90% (n = 343) had >10 TCs (CFU/g) (>10 TC CFU/g, 95% CI 87%-93%). Risk factors associated (p < 0.05) with child food contamination included if the child fed themselves (9.05 RR, 95% CI [3.18, 31.16]) and exposure to animals (2.63 RR, 95% CI [1.33, 5.34]). This study highlights the risk factors and potential control strategies that can support interventions that reduce food contamination exposure in young children and help further protect those that are highly vulnerable to recurrent exposure to enteric pathogens.

Cost-effectiveness of severe acute malnutrition treatment delivered by community health workers in the district of Mayahi, Niger

BACKGROUND

A non-randomized controlled trial, conducted from June 2018 to March 2019 in two rural communes in the health district of Mayahi in Niger, showed that including community health workers (CHWs) in the treatment of severe acute malnutrition (SAM) resulted in a better recovery rate (77.2% vs. 72.1%) compared with the standard treatment provided solely at the health centers. The present study aims to assess the cost and cost-effectiveness of the CHWs led treatment of uncomplicated SAM in children 6-59 months compared to the standard national protocol.

METHODS

To account for all relevant costs, the cost analysis included activity-based costing and bottom-up approaches from a societal perspective and on a within-trial time horizon. The cost-effectiveness analysis was conducted through a decision analysis network built with OpenMarkov and evaluated under two approaches: (1) with recovery rate and cost per child admitted for treatment as measures of effectiveness and cost, respectively; and (2) assessing the total number of children recovered and the total cost incurred. In addition, a multivariate probabilistic sensitivity analysis was carried out to evaluate the effect of uncertainty around the base case input data.

RESULTS

For the base case data, the average cost per child recovered was 116.52 USD in the standard treatment and 107.22 USD in the CHWs-led treatment. Based on the first approach, the CHWs-led treatment was more cost-effective than the standard treatment with an average cost per child admitted for treatment of 82.81 USD vs. 84.01 USD. Based on the second approach, the incremental cost-effectiveness ratio of the transition from the standard to the CHWs-led treatment amounted to 98.01 USD per additional SAM case recovered.

CONCLUSIONS

In the district of Mayahi in Niger, the CHWs-led SAM treatment was found to be cost-effective when compared to the standard protocol and provided additional advantages such as the reduction of costs for households.

TRIAL REGISTRATION

ISRCTN with ID 31143316. https://doi.org/10.1186/ISRCTN31143316.

Nutritional Status Link with Polioseronegativity Among Children from Poliomyelitis Transmission High-Risk Area of the Democratic Republic of the Congo (DRC)

Background

Malnutrition is identified as a risk-factor for insufficient polioseroconversion in the context of a vaccine-derived polio virus (VDPV) outbreak prone region. To assess the prevalence of malnutrition and its link to poliovirus insufficient immunity, a cross-sectional household survey was conducted in the regions of Haut- Lomami and Tanganyika, DRC.

Methods

In March 2018, we included 968 healthy children aged 6 to 59 months from eight out of 27 districts. Selection of study locations within these districts was done using a stratified random sampling method, where villages were chosen based on habitat characteristics identified from satellite images. Consent was obtained verbally in the preferred language of the participant (French or Swahili) by interviewers who received specific training for this task. Furthermore, participants contributed a dried blood spot sample, collected via finger prick. To assess malnutrition, we measured height and weight, applying WHO criteria to determine rates of underweight, wasting, and stunting. The assessment of immunity to poliovirus types 1, 2, and 3 through the detection of neutralizing antibodies was carried out at the CDC in Atlanta, USA.

Results

Of the study population, we found 24.7% underweight, 54.8% stunted, and 15.4% wasted. With IC95%, underweight (OR=1.50; [1.11-2.03]), and the non-administration of vitamin A (OR=1.96; [1.52-2.54]) were significantly associated with seronegativity to polioserotype 1. Underweight (OR=1.64; [1.20-2.24]) and the non-administration of vitamin A (OR=1.55; [1.20-2.01]) were significantly associated with seronegativity to polioserotype 2. Underweight (OR=1.50; [1.11-2.03]), and the non-administration of vitamin A (OR=1.80. [1.38-2.35]) were significantly associated with seronegativity to polioserotype 3. Underweight (OR=1.68; IC95% [1.10-2.57]) and the non-administration of vitamin A (OR=1.82; IC95% [1.30-2.55]) were significantly associated with seronegativity to all polioserotypes.

Conclusion

This study reveals a significant association between underweight and polioseronegativity in children. In order to reduce vaccine failures in high-risk areas, an integrated approach by vaccination and nutrition programs should be adopted.

Continuum of care for maternal and child health and child undernutrition in Angola

BACKGROUND

Continuum of care (CoC) for maternal and child health provides opportunities for mothers and children to improve their nutritional status, but many children remain undernourished in Angola. This study aimed to assess the achievement level of CoC and examine the association between the CoC achievement level and child nutritional status.

METHODS

We used nationally representative data from the Angola 2015-2016 Multiple Indicator and Health Survey. Completion of CoC was defined as achieving at least four antenatal care visits (4 + ANC), delivery with a skilled birth attendant (SBA), child vaccination at birth, child postnatal check within 2 months (PNC), and a series of child vaccinations at 2, 4, 6, 9 and 15 months of child age. We included under 5 years old children who were eligible for child vaccination questionnaires and their mothers. The difference in CoC achievement level among different nutritional status were presented using the Kaplan-Meier method and examined using the Log-Lank test. Additionally, the multivariable logistic regression analysis examined the associations between child nutritional status and CoC achievement levels.

RESULTS

The prevalence of child stunting, underweight and wasting was 48.3%, 23.2% and 5.9% respectively. The overall CoC completion level was 1.2%. The level of achieving CoC of mother-child pairs was 62.8% for 4 + ANC, 42.2% for SBA, 23.0% for child vaccination at birth, and 6.7% for PNC, and it continued to decline over 15 months. The Log-Lank test showed that there were significant differences in the CoC achievement level between children with no stunting and those with stunting (p < 0.001), those with no underweight and those with underweight (p < 0.001), those with no wasting and those with wasting (p = 0.003), and those with malnutrition and those with a normal nutritional status (p < 0.001). Achieving 4 + ANC (CoC1), 4 + ANC and SBA (CoC 2), and 4 + ANC, SBA, and child vaccination at birth (CoC 3) were associated with reduction in child stunting and underweight.

CONCLUSIONS

The completion of CoC is low in Angola and many children miss their opportunity of nutritional intervention. According to our result, improving care utilization and its continuity could improve child nutritional status.

Arm circumference for age, arm circumference and weight-for-height z-score for the evaluation of severe acute malnutrition: a retrospective cohort study in eastern Democratic Republic of Congo

BACKGROUND

Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnosing of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics.

METHODS

We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen's kappa coefficient (κ) was calculated to assess the concordance between these indicators.

RESULTS

Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 mm and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUACZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408(0.392-0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347-0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590-0.618)].

CONCLUSION

Adjusting MUAC according to age improves its effectiveness in identifying severe acute malnutrition. With low concordance, MUAC and WHZ remain complementary in our context. MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context.

Integrated child development service (ICDS) coverage among severe acute malnourished (SAM) children in India: A multilevel analysis based on national family health survey-5

Severe acute malnutrition (SAM) can be fatal for children, and potentially limit their cognitive and physical growth. The last three National Family Health Survey (NFHS) in India shows an increase in the prevalence of SAM among under-five children. Given the specific mandates under ICDS (Integrated Child Development Service) for SAM children, it is important to validate the coverage efficiency of ICDS on SAM children. This paper examines a possible association between the coverage efficiency of ICDS on SAM children. The study further aims to identify the determinants of ICDS service utilization among SAM children. We used data from the fifth round of the National Family Health Survey. Descriptive statistics was used to estimate the SAM coverage under ICDS. Multilevel Logistic Regression was used to identify the determinants of ICDS service utilization among SAM children. The burden of SAM is higher among older children (3+ age). Coverage of ICDS was more among younger children and the poorest households in the rural areas. Results from multilevel logistic regression showed that age had a significant relationship with the outcome variable. SAM children living in the rural areas had a significantly higher odds of being covered under ICDS service (OR 1.57; CI: (1.35, 1.82)) than their urban counterparts. Pregnant and lactating mothers who received ICDS services were significant determinants of SAM coverage under ICDS. There is no evidence that ICDS is more efficient in identifying and covering SAM children than non-SAM children. Despite special provisioning in place for SAM children, coverage of different ICDS services was similar to that of non-SAM children, and were in fact lower than non-SAM children for some categories. The study suggests that improving coverage of ICDS services among pregnant and lactating mothers would increase the coverage of ICDS services among SAM children.

Prevalence and Correlates of Stunting among a High-Risk Population of Kenyan Children Recently Hospitalized for Acute Illnesses

Stunting (length/height-for-age z-score < -2) is associated with significant morbidity and mortality among children under 5 years of age in sub-Saharan Africa. Children who are stunted and recently hospitalized for acute illness may be at particularly elevated risk for post-discharge mortality. In this cross-sectional analysis, we measured the prevalence of stunting at hospital discharge and identified host, caregiver, and environmental correlates of stunting among children aged 1-59 months in Western Kenya enrolled in the Toto Bora Trial. Child age- and site-adjusted prevalence ratios were estimated using Poisson regression. Of the 1,394 children included in this analysis, 23% were stunted at hospital discharge. Older children (12-23 months and 24-59 months versus 0-5 months) had a higher prevalence of stunting (adjusted prevalence ratio [aPR]: 1.58; 95% CI: 1.04-2.36 and aPR: 1.59; 95% CI: 1.08-2.34, respectively). HIV-exposed, uninfected children (aPR: 1.94; 95% CI: 1.39-2.70), children with HIV infection (aPR: 2.73; 95% CI: 1.45-5.15), and those who were never exclusively breastfed in early life (aPR 2.51; 95% CI: 1.35-4.67) were more likely to be stunted. Caregiver education (primary school or less) and unimproved sanitation (pit latrine without slab floor or open defecation) were associated with increased risk of stunting (aPR: 1.94; 95% CI: 1.54-2.44; aPR: 1.99; 95% CI: 1.20-3.31; aPR: 3.57; 95% CI: 1.77-7.21, respectively). Hospital discharge represents an important opportunity for both identifying and delivering targeted interventions for nutrition-associated poor outcomes among a high-risk population of children.

Risk factors for moderate acute malnutrition among children with acute diarrhoea in India and Tanzania: a secondary analysis of data from a randomized trial

BACKGROUND

Moderate acute malnutrition (MAM) affects over 30 million children aged < 5 years worldwide. MAM may confer a greater risk of developing severe malnutrition and even mortality in children. Assessing risk factors for MAM may allow for earlier recognition of children at risk of deleterious health outcomes.

OBJECTIVE

To determine risk factors associated with the prevalence and development of MAM among children aged 6 to 59 months with acute diarrhoea who received treatment with oral rehydration solution and zinc supplementation.

METHODS

We conducted a secondary analysis of data from a randomized, dose-finding trial of zinc among children with acute diarrhoea in India and Tanzania. We used regression models to assess risk factors for prevalent MAM at the start of diarrhoea treatment and to identify risk factors associated with the development of MAM at 60 days. MAM was defined as weight for length (or height) Z score ≤-2 and > -3 or mid-upper arm circumference < 12.5 and ≥ 11.5 cm.

RESULTS

A total of 4,500 children were enrolled; 593 (13.2%) had MAM at the baseline. MAM at baseline was significantly less common among children in Tanzania than in India (adjusted risk ratio [aRR] 0.37, 95% confidence interval [CI]: 0.30, 0.44, P < 0.001), in children aged 24- < 60 months versus 6- < 12 months (aRR 0.46, 95% CI: 0.38, 0.56, P < 0.001), and in families with household wealth index higher than the median (aRR 0.79, 95% CI: 0.68, 0.92, P = 0.002). Sixty days after outpatient treatment and follow-up, 87 (2.5%) children developed MAM. When compared to children aged 6- < 12 months, children aged 24- < 60 months had a 52% lower risk of developing MAM. Every one unit increase in weight for length (or height) Z score at enrolment was associated with a 93% lower risk of developing MAM during follow-up.

CONCLUSIONS

Among children with diarrhoea, younger children and those from households with lower wealth were at greater risk of MAM. These children may benefit from targeted interventions focusing on feeding (targeted nutrition support for at-risk households) and follow up in order to reduce the occurrence of MAM and its consequences.

Mid-upper arm circumference only protocol in Pakistan: missed opportunities for children suffering from severe acute malnutrition? A mixed-methods observational study

OBJECTIVE

We investigated the missed treatment opportunities affecting programmes using mid-upper arm circumference (MUAC) as the sole anthropometric criterion for identification and monitoring of children suffering from severe acute malnutrition (SAM).

DESIGN

Alongside MUAC, we assessed weight-for-height Z-score (WHZ) in children screened and treated according to the national MUAC only protocol in Pakistan. Besides, we collected parents' perceptions regarding the treatment received by their children through qualitative interviews.

SETTING

Data were collected from October to December 2021 in Tando Allah Yar District, Sindh.

SUBJECTS

All children screened in the health facilities (n 8818) and all those discharged as recovered (n 686), throughout the district, contributed to the study. All children screened in the community in the catchment areas of five selected health facilities also contributed (n 8459). Parents of forty-one children randomly selected from these same facilities participated in the interviews.

RESULTS

Overall, 80·3 % of the SAM cases identified during community screening and 64·1 % of those identified in the health facilities presented a 'WHZ-only' diagnosis. These figures reached 93·9 % and 84·5 %, respectively, in children aged over 24 months. Among children treated for SAM and discharged as recovered, 25·3 % were still severely wasted according to WHZ. While parents positively appraised the treatment received by their children, they also recommended to extend eligibility to other malnourished children in their neighbourhood.

CONCLUSION

In this context, using MUAC as the sole anthropometric criterion for treatment decisions (referral, admission and discharge) resulted in a large number of missed opportunities for children in need of timely and adequate care.

Nutritional treatment of children 6-59 months with severely low weight-for-age z-score: a study protocol for a 3-arm randomized controlled trial

BACKGROUND

Admission criteria that treat children with low mid-upper-arm circumference (MUAC), and low weight-for-height z-score (WHZ) are not aligned with the evidence on which children are at risk of mortality. An analysis of community-based cohort data from Senegal found that a combination of weight-for-age (WAZ) and MUAC criteria identified all children at risk of near-term death associated with severe anthropometric deficits. This study will address whether children with WAZ <-3 but MUAC ≥125 mm benefit from therapeutic feeding with ready-to-use therapeutic foods (RUTF) and whether a simplified protocol is non-inferior to the weight-based standard protocol.

METHODS

This is a prospective individually randomized controlled 3-arm trial conducted in the Nara health district in Mali. Children aged 6-59 months presenting with MUAC ≥125 mm and WAZ <-3 will be randomized to (1) control group receiving no treatment, (2) simplified treatment receiving 1 sachet of RUTF daily until WAZ ≥-3 for 2 visits, (3) standard treatment receiving RUTF according to WHZ category: (a) WHZ <-3 receive 200 kcal/kg/day until WHZ ≥-2 for 2 visits, (b) WHZ ≥-3 but <-2 receive 1 sachet daily until WHZ ≥-2 for 2 visits or (c) WHZ ≥-2 receive no treatment. All children will be followed up first fortnightly for 12 weeks and then monthly until 6 months post-enrolment. The primary endpoint will be measured at 2 months with the primary outcome being WAZ as a continuous measure. Other outcomes include other anthropometric measurements and a secondary endpoint will be observed at 6 months. A total of 1397 children will be recruited including 209 in the control and 594 in both the simplified and standard arms. The sample size should enable us to conclude on the superiority of the simplified treatment compared to no treatment and on the non-inferiority of the simplified treatment versus standard treatment with a margin of non-inferiority of 0.2 WAZ.

DISCUSSION

This trial aims to generate new evidence on the benefit of treating children with WAZ <-3 but MUAC ≥125 mm in order to guide the choice of admission criteria to malnutrition treatment and build evidence on the most efficient treatment protocol.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov: NCT05248516 on February 21, 2022.

Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique

BACKGROUND

Childhood acute malnutrition continues to be a serious health problem in many low-resource settings in Africa. On pediatric wards in Mozambique, missed opportunities for timely diagnosis and treatment of malnutrition may lead to poor health outcomes. To improve inpatient nutritional care, a quality improvement (QI) project was implemented that aimed to engage pediatric nurses in inpatient malnutrition diagnosis and treatment.

METHODS

In 2 Mozambican referral hospitals, for 6 months, the Plan-Do-Study-Act framework for QI was implemented to identify key drivers of the following measures: having complete anthropometric evaluation documented at admission, 3 or more weight measurements per hospitalization week, documentation of nutritional therapy for eligible patients, and documentation of referral for outpatient nutritional rehabilitation after discharge. Clinical data were abstracted from hospital charts and entered into an EpiInfo database, including a 3-month observation period after the project, and analyzed retrospectively.

RESULTS

A total of 2,208 children from wards other than malnutrition were included in the analysis. Complete anthropometric evaluation at admission improved from 24.4% 2 months before the QI project to 80.1% during and 75.2% in the 3 months after the project (P<.001). The percentage of patients with 3 or more weight measurements per hospitalization week rose from 22.3% to 82.8% during and 75.0% after the project (P<.001). Documentation of nutritional therapy increased from 58.8% before to 67.1% during and 70.6% after the project (P=.54), and documentation of referral for outpatient nutritional rehabilitation after discharge decreased from 55.9% to 54.9% during and increased to 70.6% after the project, (P<.001).

CONCLUSION

Nurse engagement may lead to important advancements in the diagnosis and treatment of acute malnutrition in pediatric wards other than malnutrition in Mozambique. Task-sharing, particularly nurse engagement, in combination with QI methodology, may be considered for wards in similar settings with a high burden of malnutrition.

Prediction Model with Validation for Polioseronegativity in Malnourished Children from Poliomyelitis Transmission High-Risk Area of the Democratic Republic of the Congo (DRC)

Background

Malnutrition is identified as a risk factor for insufficient polio seroconversion in the context of a vaccine-derived poliovirus (VDPV) outbreak-prone region. In the Democratic Republic of Congo (DRC), underweight decreased from 31% (in 2001) to 26% (in 2018). Since 2004, VDPV serotype 2 outbreaks (cVDPV2) have been documented and were geographically limited around the Haut-Lomami and Tanganyika Provinces.

Methods

To develop and validate a predictive model for poliomyelitis vaccine response in malnourished infants, a cross-sectional household study was carried out in the Haut-Lomami and Tanganyika provinces. Healthy children aged 6 to 59 months (n=968) were enrolled from eight health zones (HZ) out of 27, in March 2018. We performed a bivariate and multivariate logistics analysis. Final models were selected using a stepwise Wald method, and variables were selected based on the criterion p < 0.05. The association between nutritional variables, explaining polio seronegativity for the three serotypes, was assessed using the receiver operating characteristic curve (ROC curve).

Results

Factors significantly associated with seronegativity to the three polio serotypes were underweight, non-administration of vitamin A, and the age group of 12 to 59 months. The sensitivity was 10.5%, and its specificity was 96.4% while the positive predictive values (PPV) and negative (PNV) were 62.7% and 65.3%, respectively. We found a convergence of the curves of the initial sample and two split samples. Based on the comparison of the overlapping confidence intervals of the ROC curve, we concluded that our prediction model is valid.

Conclusion

This study proposed the first tool which variables are easy to collect by any health worker in charge of vaccination or in charge of nutrition. It will bring on top, the collaboration between the Immunization and the Nutritional programs in DRC integration policy, and its replicability in other low- and middle-income countries with endemic poliovirus.

Impact of a simplified treatment protocol for moderate acute malnutrition with a decentralized treatment approach in emergency settings of Niger

Introduction

Of the 45.4 million children under five affected by acute malnutrition in the world, the majority (31.8 million) are affected by moderate acute malnutrition (MAM). Its treatment is particularly complex in emergency settings such as the Diffa region in Niger. This study aims to evaluate the effectiveness and coverage of a simplified treatment protocol with Community Health Workers (CHWs) as treatment providers.

Methods

This study is a non-randomized controlled trial. The control group (n = 181) received the standard protocol currently used in country, delivered by nursing staff only in health centres and health posts, while the intervention group (n = 483) received the simplified protocol which included nursing at health centres and CHWs at health post as treatment providers.

Results

The recovery rate was higher in the simplified protocol group (99.6% vs. 79.56%, p < 0.001) recording lower time to recover and higher anthropometric gain. Treatment coverage in the intervention group increased from 28.8% to 84.9% and reduced in the control group (25.3% to 13.6%). No differences were found in the recovery rate of children treated by CHWs and nursing staff.

Conclusion

The outcomes using the simplified protocol exceeded humanitarian requirements and demonstrated improvements compared to the standard protocol showing that the simplified protocol could be safely provided by CHWs in an emergency context. Further research in other contexts is needed to scale up this intervention.

Bayesian multilevel modelling of the association between socio-economic status and stunting among under-five-year children in Tanzania

BACKGROUND

Stunting is associated with socioeconomic status (SES) which is multidimensional. This study aimed to compare different SES indices in predicting stunting.

METHODS

This was the secondary data analysis using Tanzania Demographics and Health Surveys (TDHS). The study used 7492, 6668, and 8790 under-five-year children from TDHS 2004/5, 2010, and 2015/16, respectively. The Household Wealth Index (HWI); Water and Sanitation, Assets, Maternal education and Income (WAMI); Wealth Assets, Education, and Occupation (WEO); and the Multidimensional Poverty Index (MPI) indices were compared. The summated scores, principal component analysis (PCA), and random forest (RF) approaches were used to construct indices. The Bayesian and maximum likelihood multilevel generalized linear mixed models (MGLMM) were constructed to determine the association between each SES index and stunting.

RESULTS

The study revealed that 42.3%, 38.4%, and 32.4% of the studied under-five-year children were stunted in 2004/5, 2010, and 2015/16, respectively. Compared to other indicators of SES, the MPI had a better prediction of stunting for the TDHS 2004/5 and 2015/16, while the WAMI had a better prediction in 2010. For each score increase in WAMI, the odds of stunting were 64% [BPOR = 0.36; 95% CCI 0.3, 0.4] lower in 2010, while for each score increase in MPI there was 1 [BPOR = 1.1; 95% CCI 1.1, 1.2] times higher odds of stunting in 2015/16.

CONCLUSION

The MPI and WAMI under PCA were the best measures of SES that predict stunting. Because MPI was the best predictor of stunting for two surveys (TDHS 2004/5 and 2015/16), studies dealing with stunting should use MPI as a proxy measure of SES. Use of BE-MGLMM in modelling stunting is encouraged. Strengthened availability of items forming MPI is inevitable for child growth potentials. Further studies should investigate the determinants of stunting using Bayesian spatial models to take into account spatial heterogeneity.

A Prospective Comparison of Standard and Modified Acute Malnutrition Treatment Protocols during COVID-19 in South Sudan

A non-randomized prospective cohort study was conducted in 2022 to compare recovery rate and length of stay (LoS) for acutely malnourished children treated under South Sudan's standard Community Management of Acute Malnutrition (CMAM) protocol and a COVID-modified protocol. Children aged 6-59 months received acute malnutrition (AM) treatment under the standard or modified protocol (mid-upper-arm circumference-only entry/exit criteria and simplified dosing). Primary (recovery rate and LoS) were compared for outpatient therapeutic (OTP) and therapeutic supplementary feeding programs (TSFP) using descriptive statistics and mixed-effects models. Children admitted to OTP under both protocols were similar in age and sex; children admitted to TSFP were significantly older under the modified protocol than the standard protocol. Shorter LoS and higher recovery rates were observed under the modified protocol for both OTP (recovery: 93.3% vs. 87.2%; LoS: 38.3 vs. 42.8 days) and TSFP (recovery: 79.8% vs. 72.7%; LoS: 54.0 vs. 61.9 days). After adjusting for site and child characteristics, neither differences in adjusted odds of recovery [OTP: 2.63; TSFP 1.80] nor LoS [OTP -10.0; TSFP -7.8] remained significant. Modified protocols for AM performed well. Adjusted models indicate similar treatment outcomes to the standard protocol. Adopting simplified protocols could be beneficial post-pandemic; however, recovery and relapse will need to be monitored.

Prognostics of multiple malaria episodes and nutritional status in children aged 6 to 59 months from 2013 to 2017 in Dangassa, Mali

Background

In Africa, the relationship between nutritional status and malaria remains complex and difficult to interpret in children. Understanding it is important in the development of malaria control strategies. This study evaluated the effect of nutritional status on the occurrence of multiple malaria episodes in children aged 6 to 59 months between 2013 and 2017 living in the village of Dangassa, Mali.

Methods

A community-based longitudinal study was conducted using cross-sectional surveys (SSCs) at the beginning (June) and end (November) of the malaria transmission season associated with passive case detection (PCD) at the Dangassa Community Health Center. Children with asymptomatic malaria infection during cross-sectional surveys were selected and their malaria episodes followed by PCD. Palustrine indicators in person-months were estimated using an ordinal-logistic model repeated on subjects during follow-up periods.

Results

The incidence rate (IR) during the period of high transmission (June to October), for 1 episode and for 2 + episodes peaked in 2013 with 65 children (IR = 95.73 per 1000 person-months) and 24 cases (IR = 35.35 per 1000 person-months), respectively. As expected, the risk of multiple episodes occurring during the period of high transmission was 3.23 compared to the period of low transmission after adjusting for other model parameters (95% CI = [2.45-4.26], p = 0.000). Children with anemia were at high risk of having multiple episodes (OR = 1.6, 95% CI [1.12-2.30], p = 0.011). However, the risk of having 2 + episodes for anemic children was higher during the period of low transmission (RR = 1.67, 95% CI [1.15-2.42], p = 0.007) compared to the period of high transmission (RR = 1.58, 95% CI [1.09-2.29], p = 0.016). The trend indicated that anemic and underweight children were significantly associated with multiple malaria episodes during the period of low transmission (p < = 0.001).

Conclusion

Our results indicate that multiple episodes of malaria are significantly related to the nutritional status (anemia and underweight) of the child during the two transmission seasons and more pronounced during the dry season (period of low transmission). Further research including other malnutrition parameters will be needed to confirm our findings.

Inflammation: the driver of poor outcomes among children with severe acute malnutrition?

Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.

Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells

Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.

Population-Modifiable Risk Factors Associated With Childhood Stunting in Sub-Saharan Africa

Importance

Identifying modifiable risk factors associated with childhood stunting in sub-Saharan Africa (SSA) is imperative for the development of evidence-based interventions and to achieve the Sustainable Development Goals.

Objective

To evaluate key modifiable risk factors associated with childhood stunting in SSA.

Design, Setting, and Participants

This cross-sectional study examined the most recent (2014-2021) Demographic and Health Surveys data for children younger than 5 years from 25 SSA countries.

Exposures

Modifiable risk factors included history of diarrhea within 2 weeks, consumption of dairy products, maternal body mass index, maternal educational level, antenatal care visits, place of birth, wealth index, type of toilet, and type of cooking fuel.

Main Outcomes and Measures

Stunting and severe stunting, measured using the height-for-age z score, were the main outcomes. Children who scored below -2.0 SDs or -3.0 SDs were classified as having stunted or severely stunted growth, respectively. Relative risks and 95% CIs were computed using generalized linear latent and mixed models and log-binomial link functions. Population-attributable fractions (PAFs) were calculated using adjusted relative risks and prevalence estimates for key modifiable risk factors.

Results

This study included 145 900 children from 25 SSA countries. The mean (SD) age of the children was 29.4 (17.3) months, and 50.6% were male. The highest PAFs of severe childhood stunting were observed for mothers lacking a formal education (PAF, 21.9%; 95% CI, 19.0%-24.8%), children lacking consumption of dairy products (PAF, 20.8%; 95% CI, 16.8%-24.9%), unclean cooking fuel (PAF, 9.5%; 95% CI, 2.6%-16.3%), home birth (PAF, 8.3%; 95% CI, 6.3%-10.0%), and low-income household (PAF, 5.8%; 95% CI, 3.4%-8.0%). These 5 modifiable risk factors were associated with 51.6% (95% CI, 40.5%-60.9%) of the severe childhood stunting in SSA.

Conclusions and Relevance

This cross-sectional study identified 5 modifiable risk factors that were associated with 51.6% of severe childhood stunting in SSA. These factors should be a priority for policy makers when considering future child health interventions to address chronic malnutrition in SSA.

Greater Reduction in Stunting Than Underweight and Wasting in Indian Under-Five Children: A Comparison of Growth Indicators from 4 National Family Health Surveys

OBJECTIVE

To assess change in nutritional status in Indian under-five children from four rounds of national surveys (round 1 to 4).

METHODS

National Family Health Survey data from 4 rounds (1992-2016) were analyzed. Height and weight for age (HAZ, WAZ), and weight for height (WHZ) z scores were calculated. Children under -2 z score were classified as malnourished by HAZ, WAZ and WHZ.

RESULTS

A greater reduction in stunting (from 54 to 38%, p < 0.05) than in underweight (from 44 to 34%, p < 0.05) and wasting (from 19 to 20%, p > 0.1) status over the period of 4 NFHS rounds was observed from 1992 to 2016. In line with this, combination of improved height for age (-2.1 ± 1.8 to -1.5 ± 1.7) but relatively less improved weight for age (-1.8 ± 1.4 to -1.5 ± 1.2), the change in wasting status was either nil or meagre (-0.8 ± 1.4 to -0.9 ± 1.4), (p < 0.05 for all). The percentage of children malnourished by all 3 indicators together reduced from 9 to 6% (p < 0.05). At the 4th NFHS round, higher percentage of boys (8%) than girls (6%) and rural (7%) than urban (5%) children were malnourished by all 3 indicators (p < 0.05).

CONCLUSION

Greater reduction in stunting than underweight and wasting was observed over the period of 4 rounds. There is a need for more focused efforts to combat malnutrition in rural children and boys.

Genetic variation in environmental enteropathy and stunting in Zambian children: A pilot genome wide association study using the H3Africa chip

PURPOSE

Stunting is known to be heavily influenced by environmental factors, so the genetic contribution has received little attention. Here we report an exploration of genetic influences in stunted Zambian children with environmental enteropathy.

METHOD

Children with stunting (LAZ < -2) were enrolled and given nutritional therapy. Those that were non-responsive to therapy were designated as cases, and children with good growth (LAZ > -1) from the same community as controls. Blood and stool samples were taken to measure biomarkers of intestinal inflammation, epithelial damage, and microbial translocation. Single nucleotide polymorphism array genotyping was carried out on saliva samples using the H3Africa consortium array.

RESULTS

Genome wide associations were analysed in 117 cases and 41 controls. While no significant associations with stunting were observed at P<5x10-8, likely due to the small sample size, interesting associations were observed at lower thresholds. SNPs associated with stunting were in genomic regions known to modulate neuronal differentiation and fatty acid biosynthesis. SNPs associated with increased microbial translocation were associated with non-integrin membrane ECM interactions, tight junctions, hemostasis, and G-alpha signalling events. SNPs associated with increased inflammation were associated with, ECM interactions, purine metabolism, axon guidance, and cell motility. SNPs negatively associated with inflammation overlapped genes involved in semaphoring interactions. We explored the existing coeliac disease risk HLA genotypes and found present: DQ2.5 (7.5%), DQ8 (3.5%) and DQ2.2 (3.8%); however, no children were positive for coeliac antibodies. We detected HLA-DRB:1301 and HLA-C:1802 with high odds ratios and P<0.05 in stunted children compared to controls.

CONCLUSION

Genetic variations associated with stunting and the enteropathy underlying it, include variants associated with multiple pathways relating to gene expression, glycosylation, nerve signalling, and sensing of the nutritional and microbiological milieu.

Food inflation and child undernutrition in low and middle income countries

The 21st Century has been marked by increased volatility in food prices, with global price spikes in 2007-08, 2010-11, and again in 2021-22. The impact of food inflation on the risk of child undernutrition is not well understood, however. This study explores the potential impacts of food inflation on wasting and stunting among 1.27 million pre-school children from 44 developing countries. On average, a 5 percent increase in the real price of food increases the risk of wasting by 9 percent and severe wasting by 14 percent. These risks apply to young infants, suggesting a prenatal pathway, as well as to older children who typically experience a deterioration in diet quality in the wake of food inflation. Male children and children from poor and rural landless households are more severely impacted. Food inflation during pregnancy and the first year after birth also increases the risk of stunting for children 2-5 years of age. This evidence provides a strong rationale for interventions to prevent food inflation and mitigate its impacts on vulnerable children and their mothers.

Short-Term Acceptability of Ready-to-Use Therapeutic Foods in Two Provinces of Lao People's Democratic Republic

BACKGROUND

In Lao PDR, acute malnutrition remains a public health problem, with around 9% of children under 5 being affected. Outpatient treatment of severe acute malnutrition requires ready-to-use therapeutic foods (RUTFs), but concerns have been raised about the acceptability of globally available products. Culturally acceptable RUTFs could be locally developed, but data are lacking on RUTF preferences in Lao PDR.

METHODS

In a crossover-designed study, four different RUTFs were tested for short-term acceptability and organoleptic qualities (two globally available: peanut-based, which is the current standard, and wheat-milk-based RUTFs; two regionally produced: a mung-bean-based and a fish-rice-based RUTF). Organoleptic properties were evaluated by 83 caretaker-child pair participants through a taste test and a 30 min consumption test. Short-term acceptability was assessed through a 3-day intake test. The study sites were in Phongsaly (North Laos) and Attapeu (South Laos). Focus group discussions were conducted at the beginning and the end of the study.

RESULTS

The mung bean RUTF was the favorite among caretakers, with an acceptability percentage of 96.2%, and scored better (p-value < 0.05) for all organoleptic variables than the other three RUTFs. Overall, 3 days after receiving take-home rations, the mean percentage of consumption was above 80% for all the RUTFs, with the mung bean product being the most consumed.

CONCLUSIONS

The regionally produced mung bean RUTF was the most accepted, whereas the other regionally produced fish-based RUTF was the least accepted, showing the complexity of finding culturally acceptable solutions to fight malnutrition. For Lao PDR, a mung-bean-based RUTF seems the way forward, even if the current standard peanut-based RUTF appeared to be acceptable, albeit not the most preferred.

Early-childhood linear growth faltering in low- and middle-income countries

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.

Cost of Acute Malnutrition Treatment Using a Simplified or Standard Protocol in Diffa, Niger

Evidence on the cost of acute malnutrition treatment, particularly with regards to simplified approaches, is limited. The objective of this study was to determine the cost of acute malnutrition treatment and how it is influenced by treatment protocol and programme size. We conducted a costing study in Kabléwa and N'Guigmi, Diffa region, where children with acute malnutrition aged 6-59 months were treated either with a standard or simplified protocol, respectively. Cost data were collected from accountancy records and through key informant interviews. Programme data were extracted from health centre records. In Kabléwa, where 355 children were treated, the cost per child treated was USD 187.3 (95% CI: USD 171.4; USD 203.2). In N'Guigmi, where 889 children were treated, the cost per child treated was USD 110.2 (95% CI: USD 100.0; USD 120.3). Treatment of moderate acute malnutrition was cheaper than treatment of severe acute malnutrition. In a modelled scenario sensitivity analysis with an equal number of children in both areas, the difference in costs between the two locations was reduced from USD 77 to USD 11. Our study highlighted the significant impact of programme size and coverage on treatment costs, that cost can differ significantly between neighbouring locations, and that it can be reduced by using a simplified protocol.

Changes in polyunsaturated fatty acids during treatment of malnourished children may be insufficient to reach required essential fatty acid levels - A randomised controlled trial

BACKGROUND & AIMS

Severe acute malnutrition (SAM) is a global concern. Studies on the impact of ready-to-use therapeutic foods (RUTFs) on polyunsaturated fatty acids (PUFA) are almost non-existent. The aim was to investigate the change in whole-blood PUFA and nutrition and health markers among Cambodian children with SAM after treatment with RUTFs.

METHODS

The trial was an 8-week randomised clinical trial of the effectiveness of locally produced fish-based RUTF (L-RUTF) vs standard milk-based RUFT (S-RUTF). Whole-blood fatty acids were analysed using dried blood spots. Nutrition and health markers were assessed using anthropometric assessment and blood samples for markers of inflammation. The trial was conducted at the National Pediatric Hospital, Phnom Penh, Cambodia, with one hundred and twenty-one 6-59-month-old children in treatment for SAM.

RESULTS

L-RUTF had a higher content of n-3 PUFA and a higher content of arachidonic acid (AA) and docosahexaenoic acid (DHA), while S-RUTF had the highest content of n-6 PUFA. At baseline, the children presented with a Mead acid level in whole-blood of around 0.08% of total fatty acids (FA%) and an omega-3 index of ∼0.91 ± 0.44. After eight weeks of S-RUTF treatment, linoleic acid (LA), AA, n-6/n-3 PUFA ratio, and Mead acid levels were increased. The L-RUTF intervention did not change the whole-blood PUFAs from baseline. At discharge, the children in the L-RUTF group had a lower n-6/n-3 PUFA ratio than the children in the S-RUTF group, driven by a lower alpha-linolenic acid (ALA) (0.20 vs 0.27 FA%, p = 0.004) and lower LA (15.77 vs 14.21 FA%, p = 0.018) with no significant differences in AA or DHA levels. Weight-for-height z-score at discharge was negatively associated with total PUFA (β -1.4 FA%, 95%CI. -2.7; -0.1), n-6 LCPUFA (β -1.3 FA%, 95%CI. -1.3; -0.3), and AA (β -0.6 FA%, 95%CI. -1.0; -0.2). Age-adjusted height was negatively associated with the Mead acid:AA ratio (β -1.2 FA%, 95%CI. -2.2; -0.2). No significant change was seen in inflammation markers within groups or between groups during treatment, and n-3 and n-6 PUFAs were not associated with markers of inflammation or haemoglobin status at discharge.

CONCLUSION

The trial found that whole-blood markers of PUFA status were low in children at admission and discharge from SAM treatment, indicating that the currently recommended composition of RUTFs are not able to correct their compromised essential fatty acid status. The higher content of DHA and AA in L-RUTF did not give rise to any improvement in PUFA status. No changes in health markers or associations between PUFA and health markers were found.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02907424.

Systematic Review of Management of Moderate Wasting in Children over 6 Months of Age

The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.

Growth in milk consumption and reductions in child stunting: Historical evidence from cross-country panel data

Agricultural and food policies are increasingly being tasked with doing more to improve the nutritional status of low-income populations, especially reductions in child stunting. Which specific food sectors warrant additional policy attention is less clear, although a growing body of research argues that increased animal-sourced food consumption in general, and increased dairy consumption specifically, can significantly reduce the risks of stunting, as well as deficiencies in micronutrients and high quality protein. However, experimental research on dairy's impacts on child growth in developing countries is very limited, and non-experimental evidence is confined to cross-sectional surveys. In this study we adopt a more macro lens by using a cross-country panel to show that increases in milk consumption over time are associated with large reductions in child stunting even after controlling for important confounding factors. Countries with high rates of stunting should therefore consider nutrition-sensitive strategies to increase dairy consumption among young children through both supply- and demand-side interventions.

Effect of nutrition intervention on cognitive development among malnourished preschool children: randomized controlled trial

Childhood malnutrition impairs health, development, and productivity in adulthood. Underweight children have been found to have a variety of cognitive abnormalities. The present study examined the effect of a nutrition-focused intervention on cognitive development among malnourished preschool children between 3 and 5 years of age residing in selected villages of Udupi district, Karnataka. A cluster of 12 villages was chosen randomly. The trial had enrolled preschool children (n = 253) from randomly assigned selected villages to intervention (n = 127) and control arms (n = 126). The mothers in the intervention arm received nutrition-focused intervention and reinforcement of health teaching for 12 months. The post-intervention outcome on the cognitive development of malnourished children was measured at 6 months and 12 months. Statistical analyses indicated that 52% of children in the intervention group had average cognitive development scores on the pre-test, whereas on the post-test, only 5.5% were in the average level of cognitive development. In the control group, the average cognitive development status of the children decreased from 44.4% in the pretest to 26.2% in the post-test. The cognitive development of malnourished children in the intervention group improved compared to the control group (p < 0.001). This study revealed that home-based nutrition-focused food helps to enhance children's cognitive development.Trial registration: ctri@gov.in. CTRI/31/03/2017/008273 [Registered on: 31/03/2017].

Projecting the long-term economic benefits of reducing Shigella-attributable linear growth faltering with a potential vaccine: a modelling study

BACKGROUND

Linear growth is an important outcome of child development with implications for economic productivity. Enteric infections, particularly Shigella, have been linked to linear growth faltering (LGF). However, benefits from potential reductions in LGF are rarely included in economic analyses of enteric infections. We aimed to quantify the economic benefits of vaccination related to reduced Shigella-attributable disease and associated LGF compared with the net costs of a vaccine programme.

METHODS

In this benefit-cost analysis, we modelled productivity benefits in 102 low-income and middle-income countries that had recent stunting estimates available, at least one Shigella-attributable death annually, and available economic data, particularly on gross national income and growth rate projections. We modelled benefits strictly related to linear growth improvements and no other benefits associated with reducing diarrhoeal burden. The effect size in each country was calculated as shifts in height-for-age Z score (HAZ), representing population average changes for preventing Shigella-attributable less-severe diarrhoea and moderate-to-severe diarrhoea separately for children younger than 5 years. Benefits data were calculated per country and combined with estimated net costs of the vaccine programme in the form of benefit-cost ratios (BCRs); BCRs above parity, or $1 in benefits per $1 in costs (with a 10% margin representing borderline results: 1·10:1), were considered cost-beneficial. Countries were aggregated for analysis by WHO region, World Bank income category, and eligibility for support from Gavi, the Vaccine Alliance.

FINDINGS

In the base-case scenario, all regions exhibited cost-beneficial results, with the South-East Asia region and Gavi-eligible countries exhibiting the highest BCRs (21·67 for the South-East Asia region and 14·45 for Gavi-eligible countries), and the Eastern Mediterranean region yielding the lowest BCRs (2·90). All regions exhibited cost-beneficial results from vaccination, except in more conservative scenarios (eg, those assuming early retirement ages and higher discount rates). Our findings were sensitive to assumed returns for increased height, assumptions about vaccine efficacy against linear growth detriments, the anticipated shift in HAZ, and discount rate. Incorporating the productivity benefits of LGF reduction into existing cost-effectiveness estimates resulted in longer-term cost-savings in nearly all regions.

INTERPRETATION

LGF is a secondary outcome of Shigella infection and reduction in LGF is not often quantified as a health or economic benefit of vaccination. However, even under conservative assumptions, a Shigella vaccine only moderately effective against LGF could pay for itself from productivity gains alone in some regions. We recommend that LGF be considered in future models assessing the economic and health impacts of interventions preventing enteric infections. Further research is needed on vaccine efficacy against LGF to inform such models.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust.

Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children

OBJECTIVE

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.

DESIGN

Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.

SETTING

Community-based, prospective studies from twelve countries in Africa and Asia.

PARTICIPANTS

Children aged 6-59 months living in the study areas.

RESULTS

For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.

CONCLUSIONS

Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

Association between diagnostic criteria for severe acute malnutrition and hospital mortality in children aged 6-59 months in the eastern Democratic Republic of Congo: the Lwiro cohort study

Background

Few studies have assessed the relationship between weight-for-height (WHZ) and mid-upper arm circumference (MUAC) with hospital mortality considering confounders. The particularity of MUAC for age (MUACZ) is less documented.

Objective

This study aims to investigate this relationship in a region endemic for severe acute malnutrition (SAM).

Methods

This is a retrospective cohort based on a database of children admitted from 1987 to 2008 in South Kivu, eastern DRC. Our outcome was hospital mortality. To estimate the strength of the association between mortality and nutritional indices, the relative risk (RR) with its 95% confidence interval (95% CI) was calculated. In addition to univariate analyses, we constructed multivariate models from binomial regression.

Results

A total of 9,969 children aged 6 to 59 months were selected with a median age of 23 months. 40.9% had SAM (according to the criteria WHZ < -3 and/or MUAC<115 mm and/or the presence of nutritional edema) including 30.2% with nutritional edema and 35.2% had both SAM and chronic malnutrition. The overall hospital mortality was 8.0% and was higher at the beginning of data collection (17.9% in 1987). In univariate analyses, children with a WHZ < -3 had a risk almost 3 times higher of dying than children without SAM. WHZ was more associated with in-hospital mortality than MUAC or MUACZ. Multivariate models confirmed the univariate results. The risk of death was also increased by the presence of edema.

Conclusion

In our study, WHZ was the indicator more associated with hospital death compared with MUAC or MUACZ. As such, we recommend that all criteria shall continue to be used for admission to therapeutic SAM programs. Efforts should be encouraged to find simple tools allowing the community to accurately measure WHZ and MUACZ.

Outcomes of a food voucher program and factors associated with the recovery rate of children with moderate acute malnutrition in Far North Cameroon

BACKGROUND

Research on moderate acute malnutrition (MAM) is limited, despite its high prevalence. This study examined outcomes of bi-weekly locally available foods provided via a food voucher program (FVP) on nutritional recovery [mid-upper arm circumference (MUAC) ≥ 125 mm] from MAM (defined as MUAC between 115 and 124 mm) and identified the factors associated with recovery rate in Kaélé health district, Far North Region of Cameroon.

METHODS

This was a prospective study with 474 MAM children aged 6-59 months. Food voucher distribution and MUAC screening were conducted at 6 bi-weekly visits or until the child was recovered. Time to recovery was evaluated with multivariate Cox proportional regression hazard models with associations quantified using adjusted hazard ratio (aHR). The trend for MUAC, including its determinants, was examined with multivariate linear mixed effect models.

RESULTS

The recovery rate was 78.3% by 6 weeks after the first food basket; 3.4% remained MAM, and 5.9% were transferred for treatment for severe acute malnutrition (SAM defined as MUAC < 115 mm). Boys were 34% more likely to recover from MAM than girls [aHR = 1.34, 95%CI (1.09, 1.67)]. Children aged 24-53 months were 30% more likely to recover than those aged 6-11 months [aHR = 1.30, 95%CI (0.99, 1.70)]. A one unit increase in weight-for-height Z-score (WHZ) was associated with 1.89-fold greater likelihood of recovery [aHR = 1.89, 95%CI (1.66, 2.14)]. Male children had on average 1.82 mm greater increase in MUAC than female children (p < 0.001). One unit increase in WHZ was associated with 3.42 mm increase in MUAC (p = 0.025). Children aged 12-23 and 24-53 months had 1.03 mm and 2.44 mm, respectively, greater increase in MUAC over the program than children aged 6-11 months (all p < 0.01).

CONCLUSION

The recovery rate of MAM children treated with the FVP met the Sphere standards for targeted supplementary feeding programs (> 75%). Child's WHZ, gender and age were significant factors associated with MUAC increase and recovery from MAM in the FVP. These findings indicate the FVP approach shows promise as an effective alternative treatment for MAM with consideration of associated factors and merits further evaluation.

Ethiopia National Food and Nutrition Survey to inform the Ethiopian National Food and Nutrition Strategy: a study protocol

INTRODUCTION

Ethiopia has made significant progress in reducing malnutrition in the past two decades. Despite such improvements, a substantial segment of the country's population remains chronically undernourished and suffers from micronutrient deficiencies and from increasing diet-related non-communicable diseases such as diabetes, hypertension and cancer. This survey aims to assess anthropometric status, dietary intake and micronutrient status of Ethiopian children, women and adolescent girls. The study will also assess coverage of direct and indirect nutrition-related interventions and map agricultural soil nutrients. The survey will serve as a baseline for the recently developed Ethiopian Food System Transformation Plan and will inform the implementation of the National Food and Nutrition Strategy.

METHODS AND ANALYSIS

As a population-based, cross-sectional survey, the study will collect data from the 10 regions and 2 city administrations of Ethiopia. The study population will be women of reproductive age, children aged 0-59 months, school-aged children and adolescent girls. A total of 16 596 households will be surveyed, allowing the generation of national and regional estimates. A two-stage stratified cluster sampling procedure will be used to select households. In the first stage, 639 enumeration areas (EAs) will be selected using probability-proportional-to-size allocation. In the second stage, 26 eligible households will be selected within each EA using systematic random selection. Primary outcomes include coverage of direct and indirect nutrition interventions, infant and young child feeding (IYCF) practices, food insecurity, dietary intakes, mental health, anthropometric status, micronutrient status and soil nutrient status.

ETHICS AND DISSEMINATION

The protocol was fully reviewed and approved by the Institutional Review Board of the Ethiopian Public Health Institute (protocol no: EPHI-IRB-317-2020). The study is based on voluntary participation and written informed consent is required from study participants. The findings will be disseminated via forums and conferences and will be submitted for publication in peer-reviewed journals.

Drivers of Decline in Diarrhea Mortality Between GEMS and VIDA Studies

BACKGROUND

Statistical modeling suggests that decreasing diarrhea-associated mortality rates in recent decades are largely attributed to improved case management, rotavirus vaccine, and economic development.

METHODS

We examined data collected in 2 multisite population-based diarrhea case-control studies, both conducted in The Gambia, Kenya, and Mali: the Global Enteric Multicenter Study (GEMS; 2008-2011) and Vaccine Impact on Diarrhea in Africa (VIDA; 2015-2018). Population-level diarrhea mortality and risk factor prevalence, estimated using these study data, were used to calculate the attribution of risk factors and interventions for diarrhea mortality using a counterfactual framework. We performed a decomposition of the effects of the changes in exposure to each risk factor between GEMS and VIDA on diarrhea mortality for each site.

RESULTS

Diarrhea mortality among children under 5 in our African sites decreased by 65.3% (95% confidence interval [CI]: -80.0%, -45.0%) from GEMS to VIDA. Kenya and Mali had large relative declines in diarrhea mortality between the 2 periods with 85.9% (95% CI: -95.1%, -71.5%) and 78.0% (95% CI: -96.0%, 36.3%) reductions, respectively. Among the risk factors considered, the largest declines in diarrhea mortality between the 2 study periods were attributed to reduction in childhood wasting (27.2%; 95% CI: -39.3%, -16.8%) and an increased rotavirus vaccine coverage (23.1%; 95% CI: -28.4%, -19.4%), zinc for diarrhea treatment (12.1%; 95% CI: -16.0%, -8.9%), and oral rehydration salts (ORS) for diarrhea treatment (10.2%).

CONCLUSIONS

The VIDA study sites demonstrated exceptional reduction in diarrhea mortality over the last decade. Site-specific differences highlight an opportunity for implementation science in collaboration with policymakers to improve the equitable coverage of these interventions globally.